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  • Physical and Occupational Therapy Program > Appeals

    If your GHI HMO claims have been denied for a lack of medical necessity or because there is no prior approval on file and you would like to dispute the denial, you do not request a RUR. You will receive information from Palladian regarding your clinical appeal rights so that you may file an appeal.

    If your request for RUR of a HIP claim is denied, you will receive information from Palladian regarding your clinical appeal rights. All appeals of RURs will be processed by HIP as indicated in the appropriate Dispute Resolution section of this Provider Manual: Medicaid/FHP; Commercial/CHP; or Medicare. All other appeals will follow Palladian's process which follows:

    The appeals process for Palladian is the same for GHI HMO and HIP members.

    If you do not agree with a decision regarding medical necessity, you may:

    1. Request a peer-to-peer conversation if you have not already discussed the adverse determination with the clinical peer reviewer.
    2. File a written or oral standard or expedited UR appeal or action appeal within 180 calendar days of receiving the original decision. Please note that appeals filed on behalf of Medicaid and Family Health Plus members must be filed within 90 calendar days of the date of the adverse determination letter. In addition, oral standard appeals must be followed up in writing, expedited appeals do not.

    To initiate a UR or action appeal, call Palladian's customer service department toll-free at 1-877-774-7693, Monday through Friday, from 8:30 am to 5 pm. You may initiate a written request for an appeal by sending the request to:

    Palladian Muscular Skeletal Health
    Attn: Utilization Management Department
    2732 Transit Road
    West Seneca, New York 14224

    You may submit written comments, documents, records and other information related to the case. A clinical peer reviewer who was not involved in the original decision will review the case. When Palladian does not change its original decision, you will receive information about your or your patient's further appeal rights.  Once you have completed the first level of the internal appeals process, you are entitled to a New York State External Appeal. Medicaid and Family Health Plus members may also be entitled to request a New York State Fair Hearing.

    Appeals for denial determinations made by Palladian must be submitted to:

    HIP Commercial Plans GHI HMO Plans

    Palladian Muscular Skeletal Health
    PO Box 368
    Lancaster, NY 14086-0368

    Palladian Muscular Skeletal Health
    Attn: Utilization Management Department
    2732 Transit Road
    West Seneca, NY 14224

    For Medicare members, appeals for denial determinations made by Palladian must be submitted to:

    Medicare HMO Plans Medicare PPO Plans

    EmblemHealth
    Grievance and Appeals Department
    PO Box 2807
    New York, NY 10116-2807

    EmblemHealth Medicare PPO
    PO Box 2807
    New York, New York 10017-2807

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    Glossary terms found on this page:

    An activity of EmblemHealth or its subcontractor that results in:

    • Denial or limited authorization of a service authorization request, including the type or level of service
    • Reduction, suspension or termination of a previously authorized service
    • Denial, in whole or in part, of payment for a service
    • Failure to provide services in a timely manner
    • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

    Oral or written request for EmblemHealth to review or reconsider an action by EmblemHealth or its subcontractor.

    A determination by EmblemHealth or its agents that an admission, extension of stay or other health care service has been reviewed and, based on the information provided, is not medically necessary.

    Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    A physician who possesses a current and valid license to practice medicine or a health care professional other than a licensed physician who:

    • Where applicable possesses a current and valid nonrestricted license, certificate or registration or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body to the profession
    • Is in the same profession and the same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under review

    Oral or written request to review or reconsider an initial adverse determination when waiting for a standard decision could seriously harm the enrollee's life, health or their ability to regain maximum function. For pre-service expedited requests, the practitioner may act on behalf of the member. Also called a fast track appeal.

    Written request for an independent entity that has been certified by the State to conduct a review of a denial of coverage, based on lack of medical necessity or that the service requested is experimental and investigational.

    A request to change an adverse determination that was based on administrative policies, procedures or guidelines.

    An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

    A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.

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